Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Maternal blood pressure.

Level of pain sensation.

Station of presenting part.

Variability of fetal heart rate.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.

Choice B rationale

Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.

Choice C rationale

The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.

Choice D rationale

Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .

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Correct Answer is A

Explanation

Choice A rationale

Checking serum human chorionic gonadotropin (hCG) levels is the appropriate action. hCG levels can help determine the viability of the pregnancy. Decreasing hCG levels may indicate a non-viable pregnancy, while increasing levels suggest a viable pregnancy.

Choice B rationale

Verifying the date of the last menstrual cycle is important but not the priority action in this scenario. While it can provide information on gestational age, it does not directly address the concern of vaginal bleeding.

Choice C rationale

Inquiring about the last occurrence of intercourse is not directly related to assessing the cause of vaginal bleeding. It may provide additional history but does not address the immediate concern.

Choice D rationale

Repeating a urine pregnancy test is not necessary in this context. The client is already known to be pregnant, and a urine test will not provide additional information regarding the cause of the bleeding.

A. Reduction of fever. B. Weight gain. C. Reduction of edema. D. Improved caloric intake.

Correct Answer is C

Explanation

Choice A rationale

Reduction of fever is not the primary goal of albumin therapy. Albumin's role in nephrotic syndrome is to manage severe edema, not to reduce fever, which might be managed by antipyretics if present.

Choice B rationale

Weight gain is typically undesirable in nephrotic syndrome patients due to fluid retention and edema. Albumin therapy aims to reduce edema, potentially decreasing weight as fluid balance improves.

Choice C rationale

Albumin infusion helps reduce edema by increasing plasma oncotic pressure, drawing fluid back into the vascular system. A reduction in edema indicates the therapy’s effectiveness in managing nephrotic syndrome symptoms.

Choice D rationale

Improved caloric intake is not directly affected by albumin infusion. While managing edema might improve overall well-being, albumin’s primary function in this context is fluid balance and reducing swelling.

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Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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